What a TPA actually optimises
A third-party administrator is paid to process files at volume within the insurer’s rules. It is not paid to interpret generously. Files that fit the checklist move; files that require judgement stall. Your leverage is making every file boring.
The escalation ladder exists — use it in order
Every TPA has a processor, a team lead, and an insurer-side relationship owner. Jumping straight to the insurer burns goodwill you will need for the genuinely contested file. Escalate in sequence, in writing, with the file number in the subject line.
| Situation | The move | Owner | When |
|---|---|---|---|
| File acknowledgement | Within stated SLA | Processor | Log date, chase in writing |
| First query | Named missing item only | Processor | Answer that item, nothing more |
| Repeat query, same file | Pattern, not accident | Team lead | Escalate with thread attached |
| Settlement past SLA | Working-capital cost | Relationship owner | Monthly pattern review |
| Systematic short-payment | Contract question | Insurer + your management | Quarterly, with data |
Track the desk, not just the payer
Two hospitals with the same insurer can see different outcomes because different TPA desks process them. Keep your own log of query rates and settlement lag per TPA, and raise patterns — not single files — at review meetings.
What to do on Monday
- Start a per-TPA log: queries per file, days to settle.
- Put every escalation in writing with the file number.
- Book a quarterly pattern-review meeting instead of file-by-file calls.
Worked examples on this page are illustrative arithmetic on stated assumptions, not measured market statistics.